title: Incremental cost-effectiveness of combined therapy vs medication only for youth with selective serotonin reuptake inhibitor-resistant depression: treatment of SSRI-resistant depression in adolescents trial findings.
abstract: BACKGROUND
  Many youth with depression do not respond to initial treatment with selective serotonin reuptake inhibitors (SSRIs), and this is associated with higher costs. More effective treatment for these youth may be cost-effective.
  
  
  OBJECTIVE
  To evaluate the incremental cost-effectiveness over 24 weeks of combined cognitive behavior therapy plus switch to a different antidepressant medication vs medication switch only in adolescents who continued to have depression despite adequate initial treatment with an SSRI.
  
  
  METHODS
  Randomized controlled trial.
  
  
  METHODS
  Six US academic and community clinics.
  
  
  METHODS
  Three hundred thirty-four patients aged 12 to 18 years with SSRI-resistant depression.
  
  
  METHODS
  Participants were randomly assigned to (1) switch to a different medication only or (2) switch to a different medication plus cognitive behavior therapy.
  
  
  METHODS
  Clinical outcomes were depression-free days (DFDs), depression-improvement days (DIDs), and quality-adjusted life-years based on DFDs (DFD-QALYs). Costs of intervention, nonprotocol services, and families were included.
  
  
  RESULTS
  Combined treatment achieved 8.3 additional DFDs (P = .03), 0.020 more DFD-QALYs (P = .03), and 11.0 more DIDs (P = .04). Combined therapy cost $1633 more (P = .01). Cost per DFD was $188 (incremental cost-effectiveness ratio [ICER] = $188; 95% confidence interval [CI], -$22 to $1613), $142 per DID (ICER = $142; 95% CI, -$14 to $2529), and $78,948 per DFD-QALY (ICER = $78,948; 95% CI, -$9261 to $677,448). Cost-effectiveness acceptability curve analyses suggest a 61% probability that combined treatment is more cost-effective at a willingness to pay $100,000 per QALY. Combined treatment had a higher net benefit for subgroups of youth without a history of abuse, with lower levels of hopelessness, and with comorbid conditions.
  
  
  CONCLUSIONS
  For youth with SSRI-resistant depression, combined treatment decreases the number of days with depression and is more costly. Depending on a decision maker's willingness to pay, combined therapy may be cost-effective, particularly for some subgroups.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00018902.
authors.affiliation: Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97212, USA. frances.lynch@kpchr.org
authors.forename: Frances L
authors.initials: FL
authors.lastname: Lynch
authors.forename: John F
authors.initials: JF
authors.lastname: Dickerson
authors.forename: Greg
authors.initials: G
authors.lastname: Clarke
authors.forename: Benedetto
authors.initials: B
authors.lastname: Vitiello
authors.forename: Giovanna
authors.initials: G
authors.lastname: Porta
authors.forename: Karen D
authors.initials: KD
authors.lastname: Wagner
authors.forename: Graham
authors.initials: G
authors.lastname: Emslie
authors.forename: Joan Rosenbaum
authors.initials: JR
authors.lastname: Asarnow
authors.forename: Martin B
authors.initials: MB
authors.lastname: Keller
authors.forename: Boris
authors.initials: B
authors.lastname: Birmaher
authors.forename: Neal D
authors.initials: ND
authors.lastname: Ryan
authors.forename: Betsy
authors.initials: B
authors.lastname: Kennard
authors.forename: Taryn
authors.initials: T
authors.lastname: Mayes
authors.forename: Lynn
authors.initials: L
authors.lastname: DeBar
authors.forename: James T
authors.initials: JT
authors.lastname: McCracken
authors.forename: Michael
authors.initials: M
authors.lastname: Strober
authors.forename: Robert L
authors.initials: RL
authors.lastname: Suddath
authors.forename: Anthony
authors.initials: A
authors.lastname: Spirito
authors.forename: Matthew
authors.initials: M
authors.lastname: Onorato
authors.forename: Jamie
authors.initials: J
authors.lastname: Zelazny
authors.forename: Satish
authors.initials: S
authors.lastname: Iyengar
authors.forename: David
authors.initials: D
authors.lastname: Brent
mesh_terms: D000293:Adolescent; D015928:Cognitive Behavioral Therapy / Q000191:economics*; D003131:Combined Modality Therapy / Q000191:economics; D003362:Cost-Benefit Analysis; D003511:Cyclohexanols / Q000191:economics / Q000627:therapeutic use; D003865:Major Depressive Disorder / Q000191:economics* / Q000523:psychology / Q000628:therapy*; D004351:Drug Resistance; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D017367:Selective Serotonin Reuptake Inhibitors / Q000191:economics* / Q000627:therapeutic use*; D000069470:Venlafaxine Hydrochloride
chemical_list: D003511:Cyclohexanols; D017367:Selective Serotonin Reuptake Inhibitors; D000069470:Venlafaxine Hydrochloride